I'm baaaack!

And I've already been working. Vacation was great, so of course I had to segue from that to the ER. Aww yeah.

But good came of it. I haven't been enjoying work much these last couple of weeks, but suddenly during my ER shift I realized that I was really having fun.

I was moving and grooving and treating and streeting and man I felt pretty satisfied with my life. So, life plans change. Next year I'll be applynig for a pediatric ER fellowship. So I have to figure out what to do next year.

But it'll all be good. I feel much better about the life plan now - it just feels much more right.

Back to the Dreaded Community Hospital

Actually I've been working here all December, but it didn't start to really irritate me until yesterday. I returned to Houston from visiting my cutie-patootie nephew in Dallas to work a 8p-8a overnight shift. Not a great way to start, but I got a nice snooze in the car.

The shift started fine. I like the people I was working with, and their medicine isn't crazy. But then the 21 years of constipation began for Ron, and Berkley and I got reminded why - generally speaking - humans are scum.

Between the two of us, we took care of two young women barely into their teens who had been raped by some pissant of a man. One of the girls attacked this asshole as he raped her friend and they both escaped.

And you know what? One of the girls' mothers didn't show up for three hours 'cause she was 'busy'. What the fuck? No wonder this girl was wandering around the streets of Houston - and not the best part of Houston at that - at 11pm.

But anyway, that kind of stuff is somewhat out of the ordinary, at least for the pediatric side of this hospital. The 21 years of constipation, however, aren't.

Question - if you have had abdominal pain (due to constipation that you already know about) for ten years, why come to my ER at 3am? On a Sunday night? What's, say, five more hours? You know, when you can visit your regular doctor? And if you had two children - one with seven years of constipation, one with four years of constipation - would you come to the ER at 5:30 am?

If it's my kid the answer is hell no! The best part was none of the patients wanted the one thing that would make their pain go away, at least until the next build-up of stool. So they all left in as much pain as when they showed up. Great use of resources.

Here's another one for you:

If my child has a temper tantrum, do I
a) slap him upside the head
b) take away his TV privledges
c) put him in time out (provided he is over three years old with one minute of time out per year of age)
d) call 911?

That's right - the answer is d! (A true story - someone really did call 911 for a temper tantrum. Sheesh.)

Well, I gotta go. I've got a 15 year old to see with... abdominal pain!

bad call days

When call is bad, it is just so freaking bad. Thankfully, it was my last call ever. That's right - EVER! But damn it, did it have to be as bad as it fucking was?!?

We got a 1800+ gram premature baby at about 11am. He was dead by 615pm. Babies that large (and as old as he was - 29 weeks by exam) - aren't supposed to do that badly. But this kiddo had a lot of things stacked against him - mother had no prenatal care, baby didn't get steroids prior to delivery, he was born to a mother who'd already lost several pregnancies. But still. I've never had to do chest compressions before - and God help me, I never want to do them again. It's terrifying! Am I compressing the chest enough? Am I in the right spot? Am I actually circulating any blood?

The first two times we coded the child, he came back. I did 5 minutes of chest compressions and suddenly the heart rate popped back up where it was supposed to be. Twice. Then the last time, he just... pooped out. No resurgence in heart rate, no nothing.

And of course, that time, my fellow wasn't there. I had no backup. It was freaking fantastic.

Eventually the fellow came back to the NICU, and we gave more medicine, but nothing helped. He died. It sucked.

It was my last call ever, and I never want another one like it. If I go crazy and change residencies and have to do this whole damn thing over again - I never want a call like that again.

What happened?

Okay - what the heck happened to my Red Sox? I know, I know we won last year, which should make me feel good. And I did - I do. But we were on top of the AL East for so stinking long. Why did we have to blow it at the end of the season?

Now the whole shebang might well rest on the final three game series against the Yankees. I hope they (the Yanks) all stub their toes and break their hands in the next several days!

But the good news is that I'm discharging one of my babies - and he's mostly normal! He's a former extreme preemie with multiple complications who has somehow hung on to the greater part of his brain and neurologic function. He's so freaking cute, too. He has little black curls and a big 'ole grin.

So nice.

NICU goodness

The NICU is depressing. For every baby that leaves mostly healthy and mostly normal, there seems to be five babies that either die or leave with serious neurological devistation. Which is just freaking fabulous, if you know what I mean.

I just had to go tell a mother that the Pseudomonas ventriculitis is most likely gonna kill her kid. He's not hemodynamically unstable - he looks just like he did this morning prior to his ventriculotomy. But when the neurosurgeons went in to look around, all they saw was puss. Clearly, our antibiotics aren't worth crap for this kid.

So he's gonna die. The only questions remaining are when and how.

Remind me why I like my job?

Q4 Kicks My Ass

Or, A Lesson on Terminology.

In medicine, every drug or intervention order must include a frequency. Furthermore, doctors are lazy writers. Abbreviations? Hell yes! Acronyms are good too. So instead of writing "every 4 hours" or "every day" we write "q4h" or "qday". That's a reduction of nearly 73% or 57% respectively.

As a group, residents expand this system to quantify our call nights. Call runs on a repeating schedule - every third, fourth or fifth night. Hence, q3, q4 or q5. As an intern, I had a lot of q4 months. And I did okay.

I must be old, but now q4 really kicks my ass. I feel like I'm on call or post call all the time. I'm tired, I'm cranky and my undereye circles are expanding at an exponential rate. And let's not even talk about the party my acne is having on my chin. Yuck.

But repeat after me, I'm not an intern any more! This remains cause for celebration. I only have have two months of call this year. Sooooooooooo much better than ten months, and it is soooooooooo good to NOT be on the bottom of the totem pole.

So really, life ain't bad.

Goddamn it all to hell

JJ (the kiddo who died) not only herniated (ie pushed his brain out of his skull), not only had eye findings consistent with abuse but also had relatives who had fucking reported abuse to CPS days prior to the injuries leading to his death. Apparently, these relatives had seen him covered in bruises.

Goddamnitalltohell.

Not only did he die, his death was preventable.

Not that it helps any, but the step-Dad has been arrested for homicide. I hope he roasts.

Update

So the kid I talked about in my last entery died. His pupils became fixed and dilated yesterday at about 8:30 pm.

To fight child abuse, you can donate money here. If you suspect child abuse, you can call 1-800-252-5400 in the state of Texas. For more information on Texas Child Protective Services, you can check out their website.

Remember, some folks shouldn't have kids. It is up to the rest of us to make sure those kids eventually have someplace better to go.

Post call

This is an experiment. Life always seems skewed after a night on call, and I've talked about it a lot with my hubby. But I've never written about it. He says that I'm grumpy, impatient and somewhat moody post-call. I have no idea what I am. Other than damn tired, of course.

So I thought I'd write a post-call entry today and then read it tomorrow. Just to see how the 'normal' me views the post-call me.

First let me talk about call. "Being on call" does NOT mean that I'm at home, maybe answering one or two pages from anxious mothers, sleeping peacefully in my own bed. While a resident, being on call means getting to the hospital at about 7am on day one and leaving at about 1pm on day two. Yes - that's more than 24 hours straight in the hospital.

And no, one does not sleep in a nice dark room in a quiet portion of the hospital all night while maybe one or two nurses page you about anxious mothers. As an intern it meant dealing with 2/3rds bullshit, 1/6th social chaos and 1/6th true medical problems. ALL night. As a senior resident, it means dealing with 1/4rth bullshit, 1/2 intern problems (eg how to deal with social chaos) and 1/4rth real Sickness. Of course, as an upper level the Sick patients might, at any time, stage a coup and storm the other three quarters of my time. Don't shoot til you see the whites of her eyes! Needless to say, everyone is up all night long.

So last night was a gem. Three intubated kiddos, two of which were Sick, and three regular admits. The Sickest child is likely the victim of abuse. And guess what! He's most likely gonna die. At one point last night, his intracranial pressure hit 80 mmHg.

That's bad. The goal is less than 20. Intracranial pressures of 80 = intracranial badness/impending doom.

Motherfucker. Some people just shouldn't be allowed to procreate.

On a more positive note, leftovers are good. Mmmmmmmmmm... meatloaf.

Lines, tubes and protocols

On call again.

And apparently, my formerly stable white cloud, which served me well through two years of residency, has turned black. Every freaking time I'm on call I either get really high volume or really sick kids.

Even the chief resident noticed. As a matter of fact - he made it official. He looked at me tonight and said, "Well, you have a second PICU admission on the way. I should have known - it's your call night, after all."

But first I have to explain what a white or black cloud is. A resident with a 'white cloud' is someone who has easy call nights. Few admissions, no one too sick, no social disasters, no transfers from the PICU. A resident with a 'black cloud' (which would now be me) gets multiple admissions, Sick patients, folks on other people's teams going from sick to Sick, social nightmares and issues with miscommunication between consulting services.

Oh, the joy.

It didn't used to be this way. I sailed through most nights on call, at least here at the community hospital. I never cared for more than, oh, five patients. Luscious. Apparently, that is not to be my fate this time around.

I know I sound whiny. I'm sorry, I'll stop soon. I just needed to follow in Ween's footsteps and take a moment to bitch.

On a brighter note, friends will be coming over to dinner Sunday night. Yay!

Manipulation

Dealing with nursing at the community hospital (CH) can be very interesting. I feel like I'm trapped in a bizzare roll playing simulation, where the moderator is asking the students to act out various ways to motivate the un-motivatable employee.

For example, the second and third nursing shifts weren't recording the 'ins and outs' (aka I's/Os) for AH, a 21 day old patient with poor weight gain. Tracking how much a patient takes in and how much the patient puts out (in both stool and urine) can be critical when diagnosing the etiology of failure to thrive in a baby. Basically, without the I's/Os, we can't figure out what the hell is going on. And guess what, nursing has the primary responsibility for measuring the intake and weighing diapers for the output. It is kinda sorta part of the job description. And it isn't all that hard.

So why wan't it happening?

This was my question.

But if I said or did anything at all slightly accusatory, condescending or reproving, I would earn a bad rap with the RN's. Which would be a problem. If nursing don't like ya, and you ever want to get anything done ever again - you were screwed.

Needless to say, much ass-kissing ensued. Because, of course the nurse working today would never have made such an error, and could she please educate her co-workers about the correct and proper way to do things? And was there anything I could do to make her life easier?

So you see, when you see me and my nose is brown, you'll know why.

Responsibility

Right now I'm the senior resident on the children's ward at the Community Hospital (CH) affiliated with my program. I run the ICU when the staff (ie attendings) aren't around. So if someone is intubated and ventilator dependent, it's all me. Furthermore, CH has been designated as the destination for any sick kids from the Astrodome - which means I'm waiting for the other shoe to drop. So far, so good.

But man, I can't believe that there aren't sick kids out there, just waiting to be brought to light. Scary scary. Can't you picture it? A kiddo in status asthmaticus (a very long bad asthma attack) on the verge of ventilatory failure lingering on the floor of the Astrodome until (on my call night, of course) he's found by some astute volunteer or wandering MD - then brought to me in the PICU. I just hope I can take care of whatever rolls in.

I'm not without support. I can always call the Chief Resident to get advice, who can then call a Critical Care attending over at the MSDQCH if things get too sticky, who could then call me back. But that's a lot of calling, and sometimes kids don't have a lot of time. Granted, I spent one five week long hellish month over in the MSDQCH intensive care unit trying to learn what I needed to give the kiddos what support they need until help arrives, but damn, that was only five weeks and it was last November for Pete's sake!

So far I've done okay, let's just hope tonight goes as well.

NOT quiet on the Western Front

Sorry about the lack of posts, but the MSDQCH Emergency Room is kicking my 'sorry black ass'. (Ten points for whoever can pinpont the movie reference.) For some reason, the ER is channeling the big bad Spirit of Winter - I've seen more wheezers in the last night than I want to think about. Our wait time is climbing towards six hours, and I haven't peed (or drank) in ten hours.

Not good, my friends, not good.

On another note, here's a shout out to the Ween. Happy birthday, Chica.

Bad, bad me!

So it has been eight days since posted an update. My only excuse is that I've yet again begun night riding - but unfortunately, this time I'm riding the night at the Mega-Super-Duper-Quaternary Care Hospital (MSDQCH). Night riding at the community hospital I've posted about before is like surfing a sort of calm sea. Mostly, things are quiet and predictable. Only occationally do squalls or unexpected reefs appear. Riding the night at the MSDQCH is more like gripping a lifejacket after being tumped off of the Titanic during the world's worst storm - especially in the dreaded Respiratory Bay, also known as "Up Front". The folks who come "Up Front" are much more likely to be truly Sick. Notice the capitalization. When used among doctors, "Sick" is vastly different from "sick." When one of us normal adults has a cold, we are "sick." When one is dying of massive infeciton, has been intubated (had a breathing tube placed) and requires drugs to keep the good 'ole ticker pumping, one is "Sick." To make things worse, Respiratory Bay has fifteen freaking beds! Which means at night there is only one resident to cover fifteen Sick children.

Aack!

But there are good things about working "Up Front". The proportion of bullshit dips down. And the bullshit that eeks into Respiratory Bay is funny - for example, penile problems are frequently found Up Front. Why? The triage nurse is male, and honey, does he take the weewee seriously! An otherwise routine, minor infection of the foreskin? Respiratory Bay, damnit! That thing could fall off!

So bear with me folks, and think of me as I founder in the stormy sea of the MSDQCH.

Weekends

So I'm far enough along in my residency that I actually have weekends - you know, two days off in a row.

Now, unless you are a medical resident, you don't know why this is a big deal. And even then, perhaps not. Everyone has about four days off per month. But it isn't straightforward. Some residency programs structure the schedule such that the slave - oh, sorry - I mean resident, gets a fabled Golden Weekend once a month. Notice the capital letters. The Golden Weekend is a proper noun because consecutive days off are more precious than gold. Get it? However, the joy of two consecutive days off is weighed against the pain of the occational extended string of days. And those strings are oh so freaking painful. My program frowns upon such excess torture. My program simply gives one day off per week. Which sounds okay, right?

Until you work six days a week, 80 hours a week for a year. Then you get to your second year (Yahoo! Internship is over!) and do it for six out of twelve months.

And now I've reached the haven of my final year of residency. And I have my weekends back.

Mostly.

But damn, I'm having fun with this. I went dancing last night. And I'm going to go to a movie tonight. I even got stuff done today!

I keep on waiting to wake up.

Nobody pinch me - I'll use my one day off next week to find you and kick your sorry ass.

Days off

Okay, any interns stop reading, the following is going to piss you off.

Residency is hard - time consuming, frustrating, sleep-depriving. But you get used to it. Working 80 hours becomes routine and days off are treated like precious gems. After all, you only get one a week.

Then, suddenly, late in residency rotations appear that are, well, different. Five day weeks. Multiple days off. 30 - 40 hours of actual work a week. And ya know what? It gets old. I'd rather be working a little more and goofing off a little less.

Sure, I could do stuff around the house. There's plenty to do - painting, unpacking, bug-spraying, cleaning... Not to mention catching up on the latest pediatric literature. The list doesn't end.

Huh.

There it is then: I'd rather work than actually do anything listed in the above paragraph. Who knew that I'd grow up and like my job?

Psych!

Expectations are a bitch. I'm currently a 'float' resident, which means I can get called in at any time. I've been told this... but of course as soon as I get called to work I start to bitch and moan. I don't wanna work. Especially not today.

I mean, I know that today wasn't a guarenteed day off. I know I know! But I had plans. Rock and roll, baby - isn't that more important than stoopid patient care?

(Um, yeah, I guess not.)

In other news, I'm making my first foray into furniture restoration. A minor foray. We just got a nice buffet from my mother in-law (thanks Sarah!) that, well, suffered from a little benign neglect. So I found this stuff to help. Although the packaging claims that it "eliminates white heat rings and water marks, scratches" the product doesn't quite live up to the hype. Yes, the piece looks better. No, not all of the water marks are gone.

But hey, beggars can't be choosers. And now we have a place to put the china. Cool!

Top of the pile

For one brief, shining year, my compadres and I will be... third year residents. The top of the pile, the cream of the crop, the ruler of the roost. Remember when you were a freshman in high school, back when the seniors were way old and had way more experience than you? As interns we kinda felt the same way about third years. They knew things and could find things and talked about real jobs. Now suddenly I'm one of these mythical creatures and it is a bit weird.

And I certainly don't know more than I did last month as a second year. But the idea of being a senior resident is kinda cool.

Don't get me wrong - plenty of people can still shove us around. Actually, most of the hospital can boss us around. You know: nurses, parents, hospital administration, the Chief Residents, attendings, fellows. Basically anyone who isn't a first or second year resident, or a medical student. And really, having been a medical student, intern and junior resident kinda recently, it is kinda bad form to boss them around... unless they need it. Then suddenly "bossing around" becomes "teaching". Heh.

For example, acceptable 'bossing' would be something like, "Hey, don't stick that IV in his eye! Intra-ocular absorption of ampicillin sucks!" Unacceptable might sound something like, "Get me new pager batteries! And while you are at it, get my dinner, my dry cleaning and my mail order bride! Now, get a move on, wenches!"

Heck of a weekend

So I didn't get to N'awlins.

Circumstances beyond my control, but let's not talk about that. Let's talk about how Chipotle is trying to kill me.

This is an old story, but it is just too damn good not to write about. One day I go to work in the large children's hospital ER. I plan to work my 12 hours and then get the hell out and go home. That day I was assigned to the 'Mega-Bay', which is not a 20 story android costal inlet but the area in the ER where patients who are sick and hurt, but not really that sick or hurt, go to be seen and treated. (Note: if the child is really sick, hurt or actively trying to die s/he goes to a different Bay where things move much more quickly. But ya gotta really be trying to die.) About halfway through, my stomach demands attention and sustenance, so I obligingly take myself over to Chipotle and get a barbacoa burrito. Back in the ER, I'm done with lunch and sitting in 'Mega-Bay' doing the ever-present and freaking endless paperwork. Suddenly, I feel flushed, light headed and sweaty. More scarily, my collar feels tight and I can't quite breathe right.

Ack! So my fellow resident takes me up to that other Bay I was talking about (you know, the one with the really sick kids?) and suddenly I'm a patient. I got an IV. I got Epi (epinephrine) three times. I got steroids. I got 2 liters of IV fluids. I had an anaphylactic reaction to freaking Chipotle. I also got better... eventually.

The incident has made me famous in the ER. Which is both good and bad. Now I get more teasing, smiles and winks, but the staff knows me. So when I want something, it happens a little faster than before.

And heck, even just a little fame is fun. I can say, "Oh yeah, I'm the anaphylactic resident," and people immediately know who I am, how far along in my training I've gotten and what NOT to feed me.

It's good to be the King.

"General Medicine"

The community hospital has a clinic designed to provide EC follow up for those without insurance. It's called the "General Medicine Clinic", gen med for short. The clinic also serves as the urgent care center for children seen at the hospital's pediatric clinic.

Most residents hate doing time in gen med. I love it. I just want to give cookies out to each mother that actually calls, gets a sick visit and then shows up to clinic. Each general medicine visit is an avoided ER visit. Got the crud? Come on in! We'd love to see you - just for the love of God don't take the snot to the ER. The cost to the health care system is so much greater in the ER, and a general medicine visit solves most problems. Really, no lie!

I also get to hang around all of these really smart subspecialists and basically evesdrop on all of these cool conversations. Yes, occasionally I do like to learn.